HomeMy WebLinkAboutPermit renewal request PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST
PERMIT NUMBER: ' 3ADDRESS: 650
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I, r-D h A) ���bJG ,am requesting that the above permit be renewed. I
understand that I mus—t sdhedule and pass all required inspections for the permit to be finaled. Further, I
understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a
passing inspection during any six month period during the renewal period.
Justification "'e
OWNS DR OR CONTRA R SIGNATURE DAT
to 19
Print Name
STATE OF FLORID - 1 h Ih
COUNTY OF l
ACKN WLEDGED BEFORE ME THIS DAY OF 'yWl��v' ,20 R O
I
BY WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED ( ,—�1�`e�� AS IDENTIFICATION. II
STATE OF FLORIDA,County of �
DD N
SIGN F NOTARY SEAL
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FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get%of open inspections)
Percentage:
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Original permit fee: x%open = $ Renewal fee �Rp,H IV���i,��
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Np7ARY
Revised 7/21/2014 _
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